/ EDUCATIONAL SUPPORT CENTER
1500 E. 128th Ave. • Thornton, CO 80241 • Office: (720) 972-4000 / Together – educating the whole child

2016-2017 INFORMATION RELEASE

Dear Parent/Guardian:

To save you time and effort, the information you provided on your Family Economic Data Survey can be shared with other departments within the district. We must have your permission to share your information.

Yes! I DO want school officials to share information from my Family Economic Data Survey with the District for all programs listed below for which he/she is participating. IF YOU CHECK THIS BOX YOU DO NOT NEED TO CHECK ANY OF THE BOXES BELOW.

Yes! I DO want school officials to share information from my Family Economic Data Survey with the District for the purpose of waiving District Fees.

Yes! I DO want school officials to share information from my Family Economic Data Survey with the District for the purpose of waiving School Fees.

Yes! I DO want school officials to share information from my Family Economic Data Survey with the District for the purpose of waiving Class Fees.

Yes! I DO want school officials to share information from my Family Economic Data Survey with the District for the purpose of waiving Athletic and Extracurricular Fees.

Yes! I DO want school officials to share information from my Family Economic Data Survey with the District for the purpose of waiving Exam Fees.

Yes! I DO want school officials to share information from my Family Economic Data Survey with the District for the purpose of encouraging and assisting with post-secondary planning, assistance and enrollment.

If you checked yes to any or all of the boxes above, fill out the information below. Your information will be shared only with the programs you checked, and the information will not be shared by the receiving program with anyone else.

Child’s Name: ______School: ______

Child’s Name: ______School: ______

Child’s Name: ______School: ______

Child’s Name: ______School: ______

Signature of Parent/Guardian: ______Date: ______

Printed Name: ______

Address: ______

Return this form to your school office.